Paradigm shifts

In the 1980s, a girl died in New York Hospital after she was prescribed medication by an intern and a resident. The case was a landmark one, particularly since it was highlighted that the frontliner physicians were working 30-plus hours and were thus prone to error.

Studies linking errors with sleep deprivation prompted a paradigm shift in working hour regulations for medical trainees. I thought about this when, over dinner with colleagues from medical school, we compared notes about how training was being handled in both private and public institutions. In our own training, 36-plus hour shifts with no rest were nothing out of the ordinary. The ratio of patients to trainees and the amount of work made for what was called “a boot camp for the soul,” where personal needs were secondary.

It was noble and worth it, but also difficult and thankless. To rest was unthinkable unless one was at death’s door, because the backlash wasn’t worth it: One could earn a bad reputation by napping on the job, taking a break or getting a sick leave.

A change in medical trainees’ working hours has made its way here, and the 12-hour shifts we were promised but never experienced has now become a reality for some.

For others, the reduction of working hours has taken the form of enforced rest in the middle of shifts.

At this point, the distinction has to be made between residents, who are licensed doctors in specialized training, and medical clerks and interns. The latter, under our current system, are often handled more like students and less like employees; they rotate in different departments and, depending on their programs, take exams or have protected study time. They are expected to work hard, but are not beholden to the same responsibilities and accountability as their residents.

Residents are effectively the house staff of their hospitals, expected to spend most of their time (or to “reside”) in the premises, assumed to have few obligations outside training, and paid not per hour but with a fixed income. Locally, the regulations strictly limiting work hours have not extended to include residency.

I’ve often had to stop myself (sometimes unsuccessfully) from giving into “generation-bashing”: Every generation of doctors is proud of having completed what training they had and always thinks the next generation has it easier. It’s a counterproductive attitude, since change is necessary for medical training — a province of high suicide rates and constant burnout — to improve.

Still, it’s hard to assess if shorter hours have truly helped, even abroad. For one, they result in more handoffs, from which potentially more errors arise. Moreover, it’s been shown that enforced rests are undermined by underreporting of hours and the pressure felt by trainees to stay longer to continue caring for a patient, or to accomplish paperwork.

On the other hand, there’s no arguing with the evidence that poorly rested doctors are error-prone doctors, so hospitals implement shorter shifts and hope for the best.

One major concern, at least among residents I’ve spoken with in public and private hospitals, is whether these reduced hours serve as adequate preparation for what many consider the next natural step, which is residency—a sudden propulsion to extreme hard work and responsibility.

Residency occupies a particular niche, where, grateful to be accepted to their chosen program and aware of limited opportunities, residents accept all conditions of employment, some even with poor hours and poor compensation. This is not a personal complaint, but rather the status across the board: Medicine, it seems, is brutal everywhere.

But how do we improve it, or the preparation for it? Even trainees would be appalled at the suggestion that they need to be babied, and may look at busyness and sleep deprivation as a badge of honor. Is the answer more technical and ancillary support, or more residents to handle more shifts, or an attitude change?

Maybe we could start with not glorifying sleep deprivation and work conditions that would be unacceptable to those outside the profession.

kchuarivera@gmail.com